Provider Demographics
NPI:1679857510
Name:PAIN MANAGEMENT SPECIALISTS MEDICAL GROUP
Entity Type:Organization
Organization Name:PAIN MANAGEMENT SPECIALISTS MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:BORIS
Authorized Official - Middle Name:
Authorized Official - Last Name:PILCH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:805-786-4878
Mailing Address - Street 1:PO BOX 4659
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93403-4659
Mailing Address - Country:US
Mailing Address - Phone:805-922-5655
Mailing Address - Fax:805-922-5889
Practice Address - Street 1:314 S STRATFORD AVE
Practice Address - Street 2:
Practice Address - City:SANTA MARIA
Practice Address - State:CA
Practice Address - Zip Code:93454-5903
Practice Address - Country:US
Practice Address - Phone:805-922-5655
Practice Address - Fax:805-922-5889
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-10
Last Update Date:2018-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0105740Medicaid
CA6621390002Medicare NSC
CAW18564Medicare PIN